Risk Assessments for Adolescent Depression and Suicide

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Risk Assessments for Adolescent Depression and
Suicide

• ISANNE Conference
• Inn at Mill Falls- Oct. 21, 2008
• Will White LCSW, LADAC

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Outline of talk

• Intro
• Underlying Assumptions
• Overview of depression and adolescents.
• Overview of suicide and adolescents.
• Sharing of experiences.

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• This talk is not intended to be a substitute for
  a psychiatric/psychological evaluation of an
  adolescent who may be depressed or suicidal. A
  referral to appropriate mental health
  professional should be made whenever there are
  concerns about the mental health of an adolescent.

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Underlying Assumptions

• Current research shows what teachers, counselors,
  and mothers (and some fathers) knew. The
  adolescent brain is in the process of remarkable
  change. Behaviors are erratic and similar, at
  times, to schizophrenia or other types of mental
  illness (NIMH, 2008).

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Underlying Assumptions

• During adolescents is when the first signs of
  emerging mental illness occur. Wisdom is knowing
  who is just being an adolescent or is emerging
  as mentally ill. Current research is showing
  the sooner you treat emerging mental illness the
  less brain damage.

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Depression

• Three ways to view depression
• Genetic
• Situational
• Combination of the two

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Depression

• Genetic- Good old family tree. One is born with
  the nose, ears, and disposition of some mixture
  of the past.
• Best treated with medications.

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Depression

• Situation- What is happening or happened.
• Break up.
• New school.
• Long periods of darkness (When is highest suicide
  rates?).
• When you look at retirement account.
• Other examples Trauma, Chronic drug abuse, Death
  of family members.
• According to research people bounce back to their
  state of happiness after a period of time.
  Winning a lottery or losing a loved one
  (Lyubomirsky, 2007).

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Depression

• Combination of the genetics and situation.
• Long periods of stress can impact ones mind. The
  majority of people will be resilient of
  situational depression. In some cases it will
  turns the key to unlock a long contained
  depression.
• Long periods of stress (or alcohol and other drug
  abuse) can damage the brain and create a
  difficult depression to treat.

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Depression numbers

• About 20 percent of teens will experience teen
  depression before they reach adulthood. 
• Between 10 to 15 percent of teenagers have some
  symptoms of teen depression at any one time. 
• About 5 percent of teens are suffering from major
  depression at any one time 
• As many as 8.3 percent of teens suffer from
  depression for at least a year at a time,
  compared to about 5.3 percent of the general
  population. 
• Most teens with depression will suffer from more
  than one episode. 20 to 40 percent will have more
  than one episode within two years, and 70 percent
  will have more than one episode before adulthood.
  Episodes of teen depression generally last about
  8 months. 
• A small percent of teens also suffer from
  seasonal depression, usually during the winter
  months in higher latitudes.
• (Report from the Surgeon General, 1998)

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Depression numbers

• 30 percent of teens with depression also develop
  a substance abuse problem. 
• Teenagers with depression are likely to have a
  smaller social circle and take advantage of fewer
  opportunities for education or careers. 
• Depressed teens are more likely to have trouble
  at school and in jobs, and to struggle with
  relationships.   
• Untreated depression is the number one cause of
  suicide, the third leading cause of death among
  teenagers.
• (Report from the Surgeon General, 1998)

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Adolescent Depression Paradox

• Depressed Adolescents are difficult to identify
  and can be confused with other disorders
• ALWAYS RULE OUT MEDCIAL ISSUES-
• ADD
• Substance Abuse (prescribed medication)
• PTSD
• Anxiety.
• Dysthymia

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Adolescent Depression Risk Factors

• In childhood, boys and girls appear to be at
  equal risk for depressive disorders but during
  adolescence, girls are twice as likely as boys to
  develop depression. Children who develop major
  depression are more likely to have a genetic
  history of the disorder, often a family member
  who experienced depression at an early age, than
  patients with adolescent- or adult-onset
  depression.
• (athealth.com 2008)

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Adolescent Depression Risk Factors

• Risk factors
• Stress
• Transitions
• Alcohol and drug abuse
• Long winters
• Adoption
• A loss of a parent or loved one
• Parents divorce
• Break-up of a romantic relationship
• Learning disorders
• Chronic illnesses
• Abuse or neglectOther trauma, including natural
  disasters

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Adolescent Depression Symptoms

• Sadness or hopelessness
• Irritability, anger, or hostility
• Tearfulness or frequent crying
• Withdrawal from friends and family
• Loss of interest in activities
• Changes in eating and sleeping habits (either
  way)
• Restlessness and agitation
• Feelings of worthlessness and guilt
• Lack of enthusiasm and motivation
• Fatigue or lack of energy
• Difficulty concentrating
• Thoughts of death or suicide

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Adolescent Depression Useful tools for assessment

• Extensive family and social history.
• Extensive medication and medical history.
• Conversations with current or previous
  psychotherapist.
• Conversations with support system.
• Becks depression inventory II.
• Reynolds Adolescent Depression Scale- 2.
• Mood and Feelings Questionnaire.
• Experience.

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Adolescent Depression Best Treatments for
Depression

• Cognitive Behavioral psychotherapy tends to be
  effective with situational depression.
• Medications tend to be effective with genetic
  depression.
• Combination of the two is often the best way to
  initially treat.
• Always assess for suicidality.

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Adolescent Suicide

• http//www.youtube.com/watch?vdTeytkxlDt8feature
  related

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Nationwide Suicide Numbers

• 32,000 people successfully complete suicide a
  year.
• Someone attempts suicide every minute.
• Someone successfully suicides every 16 minutes.
• Numbers do not include car accidents or
  overdose without a note.
• - (National Center for Health,2008)

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Adolescent Suicide Numbers

• Male adolescents die by suicide at a rate 4x
  higher than females.
• Female adolescents attempt suicide at a rate 3X
  higher than males
• Of all suicide completions 80 are male- 75 are
  white males.
• Asian American females aged 14-24 have the
  highest suicide rate (not attempts) of all the
  females of ethnicity
• Gay, lesbian, bisexual, transgender, questioning
  have a 4X greater risk of suicide attempts than
  heterosexuals.
• - (CDC, 2008)

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Adolescent Suicide Numbers relate to New
Hampshire

• US average of suicides per 100,000 is 10.8.
• New Hampshire average of suicides per 100,000 is
  13.3.
• Suicide is the 2nd leading cause of death after
  accidents for 10-24 year olds in NH.
• - (CDC, 2008)

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Adolescent Suicide Numbers relate to New
Hampshire

• Guns
• Presence of a firearm in a home increases the
  likelihood of a suicide by 5 times
• Rural settings
• Long winters
• Isolation.
• - (Kellermann, et al, 1992)

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Adolescent Suicide Risk Factors

• Mental health problems, including depression,
  bipolar disorder, and anxiety disorder.
• Alcohol and other substance use problems
• Loss
• Poor impulse control
• Personality disorders
• - (NAMI NH 2006)

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Adolescent Suicide Risk Factors

• History of trauma or abuse (physical, mental, or
  sexual).
• Prior suicide attempt (significantly increases
  risk)
• Fascination with death and violence
• History of bullying or interpersonal conflict
• Compulsive, extreme perfectionism.
• - (NAMI NH 2006)

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Adolescent Suicide Family Risk Factors

• Family history of suicide.
• Depressed and/or suicidal parents.
• Alcoholic and/or drug-addicted parents.
• Changes in the family structure (death, divorce,
  remarriage)
• Financial difficulties.
• - (NAMI NH 2006)

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Adolescent Suicide Indicators of risk

• Difficulties at school
• Neglect of physical appearance
• Dropping out of activities
• Sudden improvement in mood- after being down or
  withdrawn.
• Giving away favorite possessions.
• Break up with a long time partner.
• Coming out.
• - (NAMI NH 2006)

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Adolescent Suicide Need for immediate action

• Threatening to hurt or kill oneself or talking
  about wanting to hurt or kill oneself.
• Looking for or asking about ways to kill oneself
  by seeing access to firearms, pills, or other
  means.
• Writing about death, dying, or suicide.
• - (NAMI NH 2006)

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Adolescent Suicide Need for immediate action

• Rage or uncontrollable anger.
• Acting reckless.
• Withdrawing from friends, family, and society.
• - (NAMI NH 2006)

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Adolescent Suicide What to do

• Meet with student to evaluate. Evaluation for
  risk is complicated and difficult.
• There is no clear set of protocols and procedures
  that guarantee success.
• A good assessment depends on good skills and
  judgment of the clinician.
• No suicide contracts are not backed up by
  research! Although it may be a procedure there
  is little evidence of true effectiveness.
• When in doubt refer out.
• - (NAMI NH 2006)

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Adolescent Suicide What to do

• Contact parents.
• Get parents o.k. to do evaluation.
• If parents are not available and it is deemed as
  life-threatening emergency, you may perform
  evaluations without permission.
• When evaluating make sure you are in a high
  visibility area.
• Do not leave student unsupervised
• Conduct the interview in a safe and secure area
• Make sure no potentially dangerous objects are in
  office.
• Communicate with others.
• Do not agree to keep a secret.
• Find out if they are under the influence
• Ask directly about suicide.
• - (NAMI NH 2006)

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Adolescent Suicide What to dowhen a student is
voluntary.

• Find out if the student is willing to be
  hospitalized. Encourage the student that if
  they are at danger to themselves than the safest
  place to be is a hospital setting.
• If they are willing to be voluntarily admitted
  then work with the family, and their insurance
  company, to find psychiatric hospital.
• Always have the student in sight. Even in the
  bathroom!
• Call the crisis line on the insurance companies
  card to inform them of the situation and the need
  for a psychiatric hospital due to danger of self.
  Insurance companies have contracts with
  psychiatric hospitals that make it easier for
  admission.
• Work with the family and student to provide
  safe transportation to a hospital setting. If
  school has to transport due to logistics have two
  staff go with student. Before letting student in
  a vehicle ask for commitment not to harm self.
  Put student in the back of the car with one
  staff. Control locks on the doors.
• Transport student directly to emergency
  room.

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Adolescent Suicide What to dowhen a student is
involuntary.

• Find out if the student is willing to be
  hospitalized. Encourage the student that if
  they are at danger to themselves than the safest
  place to be is a hospital setting.
• Always have the student in sight. Even in the
  bathroom!
• If they are unwilling to be voluntarily
  hospitalized than you should contact your local
  mental health center and talk with crisis line.
  You will either be asked to bring the student to
  the Emergency Room or to fill out some paperwork
  in order to do a Involuntary Emergency Admission
  (IEA). Once the IEA is filled out the police can
  be called to assist you in transporting the
  student to the emergency room.
• This is a long and difficult process so be
  prepared for spending a great deal of time.

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Adolescent Suicide What happens in an emergency
room in an IEA.

• The student will be medically screened by ER
  doctor. Once student is medically clear than the
  local emergency service mental health worker will
  be called.
• The emergency service mental health worker will
  assess the student to see if they are suicidal or
  not.
• If the student is found to be suicidal (as
  decided by the mental health worker) they will
  IEA the student.
• If the student is found not to be suicidal (as
  decided by the mental health worker) you will
  have the student back with you.
• If student is IEAd they will attempt to find bed
  space some where in the state. This will take a
  long period of time.

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Adolescent Suicide What happens in an emergency
room

• If the student is found suicidal they will be
  either admitted to the hospital or will be
  transferred to a local psychiatric hospital, if
  there is a bed.
• While this process is going on- average time
  about five to eight hours.

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References

• Depression in Children and Adolescents
  Athealth.com. Kellermann AL, Rivara FP, Somes G,
  et al. Suicide in the Home in Relation to Gun
  Ownership. New England Journal of Medicine.
  1992327467-472.
• Lyubomirsky, S. (2006). The how of happiness .
  New York Penguin Press.
• NAMI website www.nami.org/
• NAMI NH website www.naminh.org/
• NIMH Website www.nimh.nih.gov/
• Center for Disease control www.cdc.gov/nchs/
• Report from the Surgeon Generalhttp//www.surgeon
  general.gov/library/mentalhealth/chapter3/sec5.htm
  l